PCOS & Hormonal Nutrition Assessment Format

PCOS, Thyroid & Hormonal Imbalance

Used by dietitians, nutrition students, hospitals and health workers across India.

Fill online | Download blank PDF (free sign-up)

What the format covers

Patient Profile

  • Registration / OPD No.
  • Date of Assessment
  • Patient Name
  • Age (years)
  • Gender
  • Contact No.
  • Address
  • Referred By
  • Ward / Bed No.
  • Occupation
  • Education
  • Modified Kuppuswamy scale class
  • Medical diagnosis / chief complaint
  • Past medical & surgical history
  • Family history
  • Physical activity level (ICMR-NIN 2020)

PCOS / Hormonal History

  • Diagnosis
  • Menstrual Cycle Length
  • Menstrual Flow
  • Current Symptoms
  • Current Medications
  • Fertility Concern

Hormonal & Metabolic Investigations

  • LH (Luteinising Hormone) (mIU/mL)
  • FSH (Follicle Stimulating Hormone) (mIU/mL)
  • LH:FSH Ratio
  • Total testosterone (ng/dL)
  • Free testosterone (pg/mL)
  • TSH (mIU/L)
  • Free T4 (ng/dL)
  • Fasting Insulin (μIU/mL)
  • HOMA-IR
  • Fasting glucose (mg/dL)
  • Prolactin (ng/mL)
  • Vitamin D (25-OH) (ng/mL)
  • AMH (Anti-Müllerian Hormone) (ng/mL)
  • USG Ovaries Findings

Anthropometric Measurements

  • Height (cm)
  • Weight (kg)
  • BMI (kg/m²)
  • MUAC (Mid-Upper Arm Circumference) (cm)
  • Waist Circumference (cm)
  • Hip Circumference (cm)
  • Waist-Hip Ratio (WHR)
  • Waist risk (Asian cut-off)
  • Waist-to-height ratio
  • Usual body weight (kg)
  • % weight change (%)
  • Body Fat % (%)
  • Ideal Body Weight (kg)
  • BMI Category (Asia-Pacific)

Dietary Assessment

  • Diet Type
  • No. of Meals/Day
  • Appetite
  • Food Allergy / Intolerance
  • Food Aversions
  • Food Preferences
  • Water Intake (litres/day)
  • Alcohol Consumption
  • Tobacco Use
  • 24-hour dietary recall — table: Time, Meal, Food / dish, Ingredients, Household measure, Approx. quantity (g/mL)
  • Food frequency — table: Frequency, Usual portion
  • Nutritional Supplements

PCOS diagnostic criteria & metabolic screen

  • Rotterdam checklist (adults; exclude alternative causes clinically)
  • Meets Rotterdam criteria (≥2 of 3)
  • Modified Ferriman-Gallwey score
  • Hirsutism screen (International PCOS Guideline 2023)
  • 75 g OGTT — 2-hour glucose (mg/dL)
  • Lipid profile — TC (mg/dL)
  • Lipid profile — LDL (mg/dL)
  • Lipid profile — HDL (mg/dL)
  • Lipid profile — TG (mg/dL)

Nutrition-Focused Physical Examination (NFPE)

  • Muscle wasting
  • Subcutaneous fat loss
  • Oedema
  • Hair
  • Eyes
  • Mouth
  • Skin
  • Nails
  • Goitre
  • Handgrip strength (optional) (kg)

Nutrition Diagnosis & Risk Stratification

  • GLIM 2019 — phenotypic criteria
  • GLIM 2019 — etiologic criteria
  • GLIM malnutrition
  • GLIM severity (assessor confirmed)
  • Overweight/obesity status
  • PES: Problem
  • PES: Etiology (Related to)
  • PES: Signs & Symptoms (Evidenced by)

Nutrition Care Plan & Recommendations

  • Energy Requirement (clinician prescribed) (kcal/day)
  • Reference (guideline) — dietitian to prescribe: Energy (ICMR-NIN 2020, healthy-adult baseline only; indicative — adjust clinically) (kcal/day)
  • Reference (guideline) — dietitian to prescribe: Protein (ICMR-NIN 2020 adult 0.83 g/kg; healthy-adult baseline only, indicative — adjust clinically) (g/day)
  • Protein Requirement (g/day)
  • Special Nutrient Focus
  • Dietary Advice / Modifications
  • Sample Meal Plan Given?
  • Next Follow-Up Date
  • Counselling Notes
  • Monitoring & Evaluation — table: Indicator, Baseline, Target, Review date, Outcome

Diet Prescription (filled by dietitian)

  • Prescribed energy (kcal/day)
  • Prescribed protein (g/day)
  • Prescribed fluid (mL/day)
  • Diet type / consistency
  • Restrictions
  • Meal plan — table: Time, Food / dish, Quantity (household measure)
  • Foods to include
  • Foods to avoid
  • Prescribed by (name, reg. no.)

Signature

  • Dietitian Name & Signature

Automatic scores in this form

  • HOMA-IR
  • BMI
  • Waist-Hip Ratio (WHR)
  • Waist risk (Asian cut-off)
  • Waist-to-height ratio
  • % weight change
  • BMI Category (Asia-Pacific)
  • Meets Rotterdam criteria (≥2 of 3)
  • Hirsutism screen (International PCOS Guideline 2023)
  • GLIM malnutrition
  • Reference (guideline) — dietitian to prescribe: Energy (ICMR-NIN 2020, healthy-adult baseline only; indicative — adjust clinically)
  • Reference (guideline) — dietitian to prescribe: Protein (ICMR-NIN 2020 adult 0.83 g/kg; healthy-adult baseline only, indicative — adjust clinically)

All calculated values are indicative — clinical judgement required.

Standards & references

  • Rotterdam 2003
  • International PCOS Guideline 2023
  • GLIM 2019
  • Nutrition Care Process (ADIME)

Frequently asked questions

What is included in the PCOS & Hormonal Nutrition Assessment format?

The format has 11 sections: Patient Profile; PCOS / Hormonal History; Hormonal & Metabolic Investigations; Anthropometric Measurements; Dietary Assessment; PCOS diagnostic criteria & metabolic screen; Nutrition-Focused Physical Examination (NFPE); Nutrition Diagnosis & Risk Stratification; Nutrition Care Plan & Recommendations; Diet Prescription (filled by dietitian); Signature. It also calculates 12 values automatically, such as HOMA-IR, BMI, Waist-Hip Ratio (WHR).

Which guidelines does the PCOS & Hormonal Nutrition Assessment follow?

It follows Rotterdam 2003, International PCOS Guideline 2023, GLIM 2019, Nutrition Care Process (ADIME). All calculated values are indicative — clinical judgement is required.

Can I download the PCOS & Hormonal Nutrition Assessment as a PDF?

Yes. After a free sign-up you can fill the form online and download both blank and filled A4 PDFs, and save private case sheets for your patients.

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